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ELECTRONIC ARTICLE: Roland Sturm, Jeanne S. Ringel, and Tatiana Andreyeva Geographic Disparities in Children’s Mental Health Care Pediatrics 2003; 112: e308 [Abstract] [Full text] [PDF]

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Multiple factors are needed to explain stimulant utilization rates

Julie M. Zito, Daniel J. Safer, MD   (5 February 2004)

Multiple factors are needed to explain stimulant utilization rates 5 February 2004
Julie M. Zito, Associate Professor of Pharmacy and Psychiatry University of Maryland, Baltimore, Daniel J. Safer, MD Send letter to journal: Re: Multiple factors are needed to explain stimulant utilization rates jzito{at}rx.umaryland.edu Julie M. Zito, et al.	To the Editor:     In their paper entitled “Geographic Disparities in Children’s Mental Health Care”, Sturm et al.1 concluded that geographic differences have a far greater impact than racial/ethnic disparities on the utilization of mental health services. Specifically, the authors state in their conclusion that “The differences in the rates of use or unmet need [of mental health care] are not driven by differences in the racial/ethnic or socioeconomic makeup across states …”  We differ on this point and offer several reasons why we believe that race/ethnicity and socioeconomic factors, in addition to geography, contribute prominently and interact to produce variations in mental health service utilization.     First, the Sturm et al. findings are not consistent with racial disparity findings based on prevalence estimates of psychotropic use from school surveys, administrative claims data and national health care survey data. In large school surveys 2 3;4(n=29,734-816,465) the White:Black (W:B) prevalence ratio for stimulant treatment ranged from 1.6:1 to 2.3:1.  Likewise, in 3 statewide prevalence studies of Medicaid enrolled youths, the W:B prevalence ratio for any psychotropic dispensing ranged from 1.7:1 to 2.4:1.5-7 National data from the 1996 Medical Expenditure Panel Survey (MEPS) on any psychotropic treatment for youths revealed a W:B medication prevalence ratio 1.7. 8   Socioeconomic data reveal more mixed findings9 but uninsured youths have a 3-fold lower prevalence of any psychotropic medication than those who are insured.8    Regional differences in psychotropic medication prevalence in the US are about as prominent as racial/ethnic differences. In the 1996 MEPS study of youths comparing psychotropic medication prevalence between regions in the US, the differences range up to 2.7:1 for stimulants and up to 2.5:1 for the use of ‘any’ psychotropic medication.8 Administrative claims data from regions show weaker disparities, although limiting the analysis to commercially insured individuals within a region may reduce the effect. For example, in the Cox et al. study, 10 the greatest regional disparity for youths with dispensed stimulants was 1.8:1 and in the Shatin and Drinkard study the greatest regional disparity for stimulants was 1.5:1.11   Second, race/ethnicity, economic and geographic factors are interrelated and the authors’ acknowledgement of a lack of statistical power to examine the interactions in this study suggests that the question is unresolved.  The interrelationship of these 3 variables is, to some extent, apparent from the data the authors presented.  If one divides the 13 states selected by the author into those above and those below the national average in mental health services for youths (7.45%), it is apparent that race and poverty sizably interact with region.  This is presented in the Table below. To clearly determine the relative importance of each of the 3 major variables on mental health services utilization, a more sophisticated analysis is required.    Third, the authors chose to measure “unmet need” in terms solely of parent report of 6 items of the child behavioral checklist. This measure has low agreement with respect to clinician or teacher ratings,12 which limits the authors’ conclusion that state-based access policies are the main reason for geographic variations in mental health care.    Moving the research agenda on unmet need forward requires prospective studies of community samples of youths so that need can be clinically assessed from multiple informants, along with measures of duration and continuity of treatment, benefits and satisfaction with mental health services. If studies adopt a contextual perspective, the interaction of race/ethnicity, economic status, and geography on the met and unmet mental health needs for US youths should become clearer.   Table. Any mental health service for youths by state in relation to population statistics on racial and poverty status (2000 census data).  State % of youths with any mental health service % white % below federal poverty level Above mean       Wisconsin 7.96 87 8.7 Washington 7.97 79 10.6 Minnesota 9.27 88 7.9 Massachusetts 11.55 82 9.3 Colorado 10.06 75 9.3 Michigan 7.65 79 10.5 New York 8.07 62 14.6         Below mean       Alabama 6.47 70 16.1 California 5.13 47 14.2 Florida 6.47 65 12.5 Mississippi 6.58 61 19.9 New Jersey 6.87 66 8.5 Texas 5.69 52 15.4 National mean            7.45         References Cited        1.    Sturm R, Ringell, JS, Andreyeva, T: Geographic disparities in children's mental health care.  Pediatrics 2003;112:e308-e315      2.    LeFever GB, Dawson KV, Morrow AL: The extent of drug therapy for attention deficit-hyperactivity disorder among children in public schools.  American Journal of Public Health 1999;89:1359-1364.      3.    Safer DJ, Malever M: Stimulant treatment in Maryland public schools.  Pediatrics 2000;106:533-539.      4.    Rowland AS, Umbach DM, Stallone L, Bohlig EM, Sandler DP: Prevalence of medication treatment for attention deficit-hyperactivity disorder among elementary school children in Johnston County, North Carolina.  Am J Public Health 2002;92:231-234.      5.    Rushton JL, Whitmire JT: Pediatric stimulant and SSRI prescription trends: 1992-1998.  Arch Pediatr Adolesc Med  2001;155:560-565.      6.    Martin A, VanHoof T, Stubbe D, Sherwin T, Scahill L: Multiple psychotropic pharmacotherapy among child and adolescent enrollees in Connecticut medicaid managed care.  Psychiatric Services 2003;54:72-77.      7.    Zito JM, Safer DJ, dosReis S, et al: Psychotropic practice patterns for youth: a ten-year perspective.  Arch Pediatr Adolesc Med 2003;157:17-25.      8.    Olfson M, Marcus SC, Weissman MM, Jensen PS: National trends in the use of psychotropic medications by children.  J Am Acad Child Adolesc Psychiatry 2002;41:514-521.      9.    Safer DJ, Zito JM: Pharmacoepidemiology of psychotropic medications in youth, in Rosenberg DR, Davanzo PA, Gershon S (eds): Pharmacotherapy for Child and Adolescent Psychiatric Disorders. New York, Marcel Dekker, Inc.; 2002:p. 28.    10.    Cox ER, Motheral BR, Henderson RR, Mager D: Geographic variation in the prevalence of stimulant medication use among children 5 to 14 years old: results from a commercially insured US sample.  Pediatrics 2003;111:237-243.    11.    Shatin D, Drinkard CR: Ambulatory use of psychotropics by employer-insured children and adolescents in a national managed care organization.  Ambulatory Pediatrics 2002;2:111-119.    12.    Achenbach TM, McConaughy SH, Howell CT: Child/adolescent behavioral and emotional problems: implications of cross informant correlations for situational specificity.  Psychological Bulletin 1987;101:213-232.